Medicaid Cover Breast Reduction 2024

Yes, you heard it right! Medicaid can pay for your breast reduction in many cases. However, to get approved your procedure by Medicaid, it must be considered medically necessary by an authorized health practitioner. That means, your Medicaid cover breast reduction has to be related to a medical condition. 

In case, you are looking for Medicaid cover breast reduction for cosmetic purposes, then you’ll not get approved by Medicaid. And you have to settle the entire bill from your pocket. Sometimes Medicaid may recommend some alternative ways like physical therapy and weight loss. But if you have any records from a health practitioner then Medicaid will commence a surgery preauthorization. In this article, we discuss in detail about Medicaid covers breast reduction.

Does Medicaid Cover Breast Reduction?

In the United States, more than 10 million people are living and getting benefits of medicare and Medicaid at the same time. This simply means that they are dual eligible because they are federally qualified for medicare. Even, if they meet their home state’s qualifications for Medicaid. 

A beneficiary who has dual eligibility gets all expenses cover first by medicare. After that, Medicaid pays the other expenses and services remaining. These expenses included deductibles, copayments, and coinsurance costs. And yes, coverage includes surgeries like breast reduction. 

Qualifications are completely based on individual circumstances. Whether they have full or partial dual eligibility coverage is determined by the regulation of their home state. In simple words, if you have full coverage then Medicaid pays for such procedures and services that medicare does not. In case, if you have partial coverage, then Medicaid covers the cost of medicare premiums and other cost-sharing expenses. 

In the United States, most states use the SSI which stands for federal supplemental security income. SSI income and asset guidelines determine eligibility. People whose income is 300 percent less or the limit of supplemental security income then they are eligible for full dual coverage.

In 2019, the supplemental security income limit is $771.00 per month. So, 300% of that is $2323.00 per month. States that apply for SSI have a $2000.00 limit on countable assets per person. In case, both people are in marriage then the limit is $3000.00. Remember, these assets don’t include your home. 

In the United States, every state has sets of regulations for resources and income allowances. You can easily find your state’s information online or at a local Medicaid services office.

Qualifications For Breast Reduction Medicaid 

If you want Medicaid to cover breast reduction Medicaid then you have to qualify for it. To qualify you to have to fulfill some conditions that are made by the authorities of Medicaid. And your physician will verify this. 

1. You didn’t get success with non-surgical procedures.
2. Your symptoms have been present for the last six months. 
3. This breast reduction Medicaid surgery reduces your pain. 

If you want to get all the benefits. Then your breast reduction surgery must be done in a Medicaid-approved location. Before getting any appointment, kindly ask your doctor if they accept Medicaid. You can also find online such doctors who accept Medicaid.

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Which Breast Reduction Surgery Medicaid Pay For?

To get benefits of Medicaid. You should be aware of which surgeries does Medicaid pay for? So, here are some mentioned surgeries that are done in Medicaid. You can even ask about this in your local Medicaid offices. You can also directly call them using their helpline number.

• Reduction Mammoplasty

Breast reduction surgery Medicaid pays for reduction mammoplasty. It covers cases of genetic deficiency, loss of substantial contralateral female breast tissue due to trauma, or any other conditions. It will be covered if the surgery is necessary due to the high risk of cancer. 

• Mastectomy For Male Gynecomastia

Mastectomy for gynecomastia is an operation that is done to remove breast tissue from adult males. Male gynecomastia occurs when the male mammary glands grow too much. There are few conditions to meet the eligibility criteria and to get qualified for Medicaid. 

1. The adult recipient must have a history that exceeds three months, even if the pathological causes have been ruled out. 
2. And for teenagers, it must have a history far more than six years after any pathological causes have been ruled out. 
3. The excess tissue must not be fatty. But granular as determined by a mammogram. 
4. Prescriptions, Illegal drugs, and alcohol should not cause excess tissue growth. 

• Breast Reconstructive Surgery

Breast reconstructive surgery is done after a mastectomy surgery to create balance with the contralateral breast. It includes the surgical creation of a new breast mound and also the reconstruction of nipples. And for this surgery Medicaid breast reduction approval is provided to those people who are eligible for it. 

Importantly, physicians must provide documentation that includes photos that confirm severe disfigurement due to disease, trauma, or surgical complications. 

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• Prophylactic Mastectomy

Prophylactic mastectomy is the extraction of the mammary glands to prevent the growth of cancerous cells in an individual’s body. Here also when people meet the conditions they get the benefits of Medicaid. 

• If the recipient has a history of breast cancer. 
• When a health practitioner reveals that the recipient is at a high risk of contracting breast cancer. 

Conclusion

If you are still questioning that “does Medicaid pay for breast reduction?”. Then, the answer is yes. Yes, Medicaid will pay for breast reduction when the criteria they set are met. However, Medicaid doesn’t pay for breast reduction for cosmetic purposes. In this article, we discussed in detail Medicaid cover breast reduction. Thanks for reading!